Application for claiming refund of medical expenses incurred in connection
with medical attendance of students , members of staff of the Indian Institute
of Technology and their families. / (N.B. Separate form should be used for each patient)
I. Status Information of the claimant (in block letters) :
I hereby declare that the statement made in this application are true
to the best of my knowledge and belief/and the person for whom medical
expenses were incurred is wholly dependent upon me and is not an earning
member of the family
Countersigned and certified that the claim :
Certificate granted to Mr./Mrs./Miss wife/husband/son/daughter/father/mother of Mr./Mrs. employeed in the institute.
1. Dr. hereby certify :-
N.B. : Certificates not applicable should be striken off.Certificate
(c) is compulsory and must be filled in by the medical Officer-in Charge,
in all cases.